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Home My WebLink AboutNCG080334_MONITORING INFO_20190103STORMWATER DIVISION CODING SHEET NCG PERMITS PERMIT NO. 1v Cc, Oq � J3 DOC TYPE ❑HISTORICAL FILE N MONITORING REPORTS DOC DATE ❑ Ao )j o) D3 YYYYMMDD STORMWATER DIVISION CODING SHEET NCG PERMITS PERMIT NO. NCGNE DOC TYPE ❑ HISTORICAL FILE DOC DATE ❑ YYYYM M DD Semi-annual Stormwater Discharge Monitoring Report for North Carolina Division of Water Quality General Permit No. NCG080000 Date submitted 1212BL2018 CERTIFICATE OF COVERAGE NO. NCGO80334 FACILITY NAME Republic Waste Services Inc. — Winston Salem COUNTY Forsyth ^ PERSON COLLECTING SAMPLES Mark Tabacznski LABORATORY ENCO Lab Cert. # 591 Comments on sample collection or analysis: SAMPLE COLLECTION YEAR 2018 SAMPLE PERIOD ❑ Jan -June ® July -Dec CE or ❑ Monthly' (month) RECEIVED IIHARGING TO CLASS ❑ORW ❑HQW []Trout ❑PNA JAN 0 3 2019 ❑Zero -flow []water Supply ❑SA ®Other C, CENTRAL FILES DWR SECTIOM PLEASE REMEMBER TO SIGN ON THE REVERSE 4 Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _x_ yes (if yes, report your analytical results in the table immediately below) Part A: Vehicle Maintenance Areas Monitoring Requirements (if applicable) no ❑ No discharge this period' Outfall No: Date Sample Collected; mo/dd/yr 00530 00400 00556 .. Total,'Suspended; 5ohds,,mg/! pH, Standard`=units Non -Polar Oil and.;Grease/TPH'EPA . Metho&1664 (SGT=HEM); mg/L NewtMotor O.il+Usage, Annuab546 ag0gal/mo Benchmark' - 50 or400 see permit Within 6A'— 9.6 15 - 001 11/09/2018 12 6.7 2.70 —80-90 gal/mo. Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals (If applicable) Outfal l No. Date Sample Collected, mo/dd/yr 00556 00530 00400 Non -Polar Oil and Grease/T:PH EPA Method 1664 (SGT-HEM), mg/L Total Suspended:Solidsi mg/L pH; Standard units Permit Limit - 15 50 or 100 see permit 6.0 — 9.0 For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here. SWU-250 Iasi revised April 11, 2013 Page I of 2 STORM EVENT CHARACTERISTICS: Date _11/09/2018 (first event sampled) Total Event Precipitation (inches): 0.37 Date (list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 1, or Tier 3 responses. See General Permit text. FOR PART A AND PART B MONITORING RESULTS: • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART it SECTION B. • 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B. • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO ❑ IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mail an original and one copy of this DMR, including all "No Discharge" reports, within 30 days of receipt of the lab results for at end of monitoring period in the case of "No Discharge" reports) to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalits forsubmitting false information, including the possibility of fines and imprisonment for knowing violations." (Signature of Permittee) (Date) "— Additional copies of this form may be downloaded at: http://portal.ncdenr.orp/web/wg/ws/su/npdessw#tab-4 SWU-250 last revised April 1 I, 2013 Page 2 of 2 Semi-annual Stormwater Discharge Monitoring Report for North Carolina Division of Water Quality General Permit No. NCG080000 Cr~ o a 3-3Date submitted ��%"�17 - CERTIFICATE OF COVERAGE No. NCG08 0 d 0 SAMPLE COLLECTION YEAR 7 FACILITY NAME T� i Tom M SAMt R O) ❑ Jan -June 1 July -Dec COUNTY S TIC or ❑ Monthly' [month} PERSON COLLECTING SAMPLES 6?1✓ Z r ESDFStIP�G TO CLASS ❑ORW ❑HQW []Trout ❑PNA ❑Zero -flow Water Supply ❑SA LABORATORY ��Gy Lab Cert. ft ;,� f �� FILES ❑Other Comments on sample collection or analysis: SECTIONYR - PLEASE REMCMBER TO 51GN ON THE REVERSE Part A: Vehicle Maintenance Areas Monitoring Requirements ❑ No discharge this perioqvy Outfali No. Date Sample Collected, mo/dd/ r 00530 00400 00556 Total Suspended Solids, mg/L PH, Standard units Non -Polar Oil and Grease/TPH EPA Method 1664 (SGT-HEM), mg/L New Motor Oil Usage, Annual average gal/mo Benchmark - 50 or 100 see Permit Within 6.0 _ 9.0 15 la . 7 6 Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes Vno (if yes, report your analytical results in the tabfe immediately below) Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals Outfall No. Date Sample Collected, mo/dd/yr 00556 00530 00400 Non -Polar Oil and Grease/TPH EPA Method 1664 (SGT-HEM), mg/L Total Suspended Solids, mg/L pH, Standard units Permit Limit 15 50 or 100 see permit 6.0 - 9,0 .y- 7 Far sampling periods with no discharge at any single outfall, you must still submit this discharge ronitoring report with a checkmark here. �v. e 2 o 20, sE L �it�S C?7DA! 5WU-250 Iasi revised October2 .20F2 Page I of 2 STORM EVENT CHARACTERISTICS: Date 1,2 1 7 (first event sampled) Total Event Precipitation (inches): Date (list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 1, or Tier 3 responses. See General Permit text. FOR PART A AND PART B MONITORING RESULTS: • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART It SECTION B. • 2 EXC£EDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME Oil TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART P SECTION 8. • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mail an original and one copy of -this DMR including_ all "No Discharge" reports, within 30 days of receipt of the lob results for at end of monitoring period in thg case o "No Discharge" re orts to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIC; IV THIS CLRTIriCAI ION FOR ANY INFORMATION REPORTEA: "t certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a systern designed to assure that qualified persannei properly gather and evaluate the information submitted Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and hefief, true, accurate, and complete. I am aware that there are significant pen i for submitting false information, including the possibility of fines and imprisonment for knowing violations." OdII � J g (Signature of Permitteel (Datel Additional copies of this form may be downloaded at: httj�"' inrt<�I.rii[I¢ i3r gig/wef�v,-y/ws s I�_�ri,clNsswiltaE,_1 - 1%VU-250 last re%ised Uctnhet 25. 201 7 Pave 2 4-1 4 Semi-annual Stormwater Discharge Monitoring Report for North Carolina Division of Water Quality General Permit No. NCG080000 a A-O rJ -2 Date submitted ��h7. CERTIFICATE OF COVERAGE No. NCG08 n D 1 SAMPLE COLLECTION YEAR --0 / 7 K; FACILITY NAME 8L1'C WAS WfIVSr01V SAMPLE PERIOD Mn-June ❑July -Dec Y 'Il�COUNT:Ae-S}orMonthly` month) PERSON COLLECTING SAMPLES R 'aa C E v GRL„a G TO CLASS ❑ORW ❑HQW [Trout []PNA LABORATORY t9rMd _ Lab Cert. # ❑Zero -flow []WaterSupply ❑SA Comments on sample collection or analysis: JUL ] 2 J0I/ []Other__ CENTRAL FILES PLEASE REMEMBER TO SIGN DiV "fHE REVERSE � Part A: Vehicle Maintenance Areas Monitoring Requirements i7WR SECTION ❑ No discharge this period' Outfall No. Date Sample Collected, mo/dd/yr 00530 00400 00556 Total Suspended Solids, mg/L pH, Standard units Non -Polar Oil and Grease/TPH EPA Method 1664 (SGT-HEM), mg/L New Motor Oil Usage, Annual average gal/mo Benchmark - 50 or 100 see permit Within 6.0 — 9.0 1s 3 •S Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? yes _no (if yes, report your analytical results in the table immediately below) Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals Outfall No. Date Sample Collected, mo/dd/yr 00556 00530 00400 Nan -Polar Oil and Grease/TPH EPA Method 1664 (SGT-HEM), mg/L Total Suspended Solids, mg/L pH, Standard units Permit Limit 1s 50 or 100 see permit 6.0 — 9A I For sampling periods with no discharge at any single outfail, you must still submit this discharge monitoring report with a checkmark here. S�VLJ-250 last revised October 25. 2012 Page 1 of 2 STORM EVENT CHARACTERISTICS: Date Z (first event sampled) Total Event Precipitation (inches}: Date _ (Fist each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier1, or Tier 3 responses. See General Permit text. FOR PART A AND PAR B MOWTORfNG RESULTS'. • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS, SEE PERMIT PART II SECTION B. 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS, SEE PERMIT PART II SECTION B. • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑ IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES [] NO ❑ REGIONAL OFFICE CONTACT NAME: ail an original and ne copy of this DMR inciudr ail "No Discharge' reports, withi 30 days of receipt gf the lab results for at end of monitoring periodin the case of "No Discharge" reports) to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted Based on my iriquiry of the person or persons who manage the system, or those persons directly responsible for gat 'ng the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and ccrnplete I am aware that there are /s'ficant penalties itting false information, including the possibility of fines and imprisonment for Knowing violations." lam! t=�� (Signature of Permitteel (Date) Additional copies of this form may be downloaded at: htip_f SIUU-250 last revised October 25, 2012 Page 2 of'2 Semi-annual Stormwater Discharge Monitoring Report for North Carolina Division of Water Quality General Permit No. NCGO80000 Date submitted _ 6� CERTIFICATE OF Cj9,VERAGE NO. NCGO800 0 O FACILITY NAMEiC-�PU�I<_ COUNTY AQrTILt _ PERSON COLLECTING SAMPLES viLA/ZC 719/�4CZY/1/SC+f LABORATORY &NGo Lab Cert. # Comments on sample collection or analysis: Part A: Vehicle Maintenance Areas Monitoring Requirements SAMPLE COLLECTION YEAR c;VV 7 SAMPLE PERIOD ®Jan -June ❑ July -Dec or ❑ Monthly' _ {month) DISCHARGING TO CLASS [:JORW E]HQW [Trout (]PNA QZero-flow []watersupply ❑SA ❑Other PLEASE REiV IEMBLR 10 SIGN ON THE REVERSE No discharge this period' outfall No. Date Sample Collected, ^�- 00530 00400 00556 Total Suspended Solids, mg/L pH, Standard units Non -Polar Oil and Grease/TPH EPA Method 1664 (SGT-HEM), mg/L New Motor Oil Usage, Annual average gal/mo Benchmark 50 or 100 see permit Within 6.0-- 9.0 15 Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _yes _no (if yes, report your analytical results in the table immediately below) Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals Qutfall No. Date Sample Collected, mo/dd/yr 00556 005.30 00400 Non -Polar Oil and Grease/TPH EPA Method 1664 (SGT-HEM), mg/L Total Suspended Solids, mg/L pH, Standard units Permit Limit 15 50 or 100 see permit 6.0 - 9,0 I For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here. 5 ti U-250 last revised Ociober 2.5, 2012 i'agc I of 2 STORM EVENT Ci1ARACTEIRISTICS: Date a& (first event sampled) Total Event Precipitation (inches): Date (list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text. FOR PARTA AND PART B MONITORING RESULTS: • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B. • 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS, SEE PERMIT PART 11 SECTION B. • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME, ail an original and one copy of this DMR, includina all "No Discharcre" reports. within 30 days of receipt oLth�ib results (or at end of mQnitorina period in the case of 'No llischarae"renortsl to: Division of Water Quality Ann, DWQ Central Files 1617 Mail Service Center Raleigh, North Caroiina 27699-1617 YOU MUST SIGN THIS CERTIFICl1 f10N FOR ANY INFORMATION REPORTED. "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for_submitting false information, including the possibility of fines and imprisonment for knowing violations." 07//0 '-; > (Signature of Permittee) (Date) Additional copies of this form may be downloaded at: h j(�iartal.n�clerir ur /weir yJLi nyu� �pdes.sw9tab_4 SWU-250 Iasi rc6sed Oclohcr 2+5- 2012 I'agc 2 n1'2 RECEIVED DEC 2 9 2016 Semi-annual Stormwater Discharge Monitoring Report CENTRAL FILES for North Carolina Division of Water Quality General Permit No. NCG080000 DWR SECTION Date submitted /,44A CERTIFICATE OF COVERAGE NO. N0008 O O D to FACILITY NAME Z01144/"G W,A1-rTa/v COUNTY i-Oe4)rr T _ - PERSON COLLECTING SAMPLES /nAZC f W��J _ LABORATORY B/lC4 Lab Cert. # Comments on sample collection or analysis: Part A: Vehicle Maintenance Areas Monitoring Requirements SAMPLE COLLECTION YEAR 4fA%g SAMPLE PERIOD ❑ Jan -June July -Dec or ❑ Monthly; (month) DISCHARGING TO CLASS ❑ORW ❑Haw ❑Trost ❑PNA ❑Zero -flow [:]watersupply ❑5A JT ❑0ther PLEASE REMEMBER TO SIGN ON THE REVERSE -) No discharge this period' Outfall No. Date Sample Collected, r mo/dd/ 00530 00400 00556 Total, Suspended Solids, m L pH, Standard units Non -Polar Oil and Grease/TPH EPA Method 1664(SGT-HEM), mg/L ; New Motor Oii Usage, Annual avers a al/mo Benchmark - 50 or 100 see in0mit Within 6.0 - 9,0 15 Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes _no (if yes, report your analytical results in the table immediately below) Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals Outfall No. Date Sample Collected, mo/dd/ r 00556 00530 00400 Non -Polar Oil and Gre'ase/TPH EPA Method 1664 (SGT-HEM), mg/L Total Suspended Solids, mg/L pH, Standard units Permit Limit - i5 50 or 100 see permit 6.0 — 9.0 For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here. 5 W U-250 last revised October 25, 2012 Page I of 2 STORM EVENT CHARACTERISTICS: Date % 40 (first event sampled) Total Event Precipitation (inches): Date (list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, TFer 2, or Tier 3 responses. See General Permit text. FOR PART A AND PART B iyiONl_ TQRILG RESULTS • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B. • 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART ll SECTION B. • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑ IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mail -an original and g1je cojoy o DW& including all 'No Discharge' reports, within 39 days o r cei of thgb results jQr at end of m n'tor eriod in the case of. "No Discharae" reports to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699.1617 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED "i certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the info ation, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are s' ' icant penalties for submitting fa formation, including the possibility of Fines and imprisonment For knowing violations," (Signature of Permittee) (Date) Additional copies of this form may be downloaded at: �ijxiesswlftab_4 S W U-250 lost rcvised October 25, 2012 Page 2 of 2 RECEIVED DEC 2 9 2016 Semi-annual Stormwater Discharge_ Monitoring Report CENTRAL FILES for North Carolina Division of Water Quality General Permit No. NCGO80000 DWR SECTION N"-bp�Date s�ubbmitted Pl aIM,-��g//' CERTIFICATE OF COVERAGE NO. NGG 0$_ {O0- �� ! SAMPLE COLLECTION YEAR �`�r `� SAMPLE PERIOD Jan -June ul Dec FACILITY NAME �Bl�L- �.✓r43'7�° ttJi��7�t�_ ij'%� y` COUNTY ?So T74 or []Monthly' month PERSON COLLECTING SAMPLES MAW— ^I-Q r� DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout [JPNA LABORATORY Ca Lab Cert. 0 ❑Zero -flow ❑Water Supply []SA Comments on sample collection or analysis: [-]Other PLEASE REMEMBER TO SIGN ON THE REVERSE a Part A. Vehicle Maintenance Areas Monitoring Requirements No discharge this period' Outfall No. Date Sample Collected, mo/dd/yr 00530 00400 100556 Total.Suspended Solids, mg/L PH, Standard units Non -Polar Oil and:Grease/TPH EPA Method 1664.(SGT-HEM), mjjL New Motor Oil Usage, Annual average gal/mo Benchmark 50 or 100 see Permit Within 6.0 - 9.0 1s Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?_ yes _no (if yes, report your analytical results in the table immediately below) Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals Outfall No. Date Sample Collected, mo/dd/yr 00556 00530 00400 Non -Polar Oil and Grease/TPH EPA Method 1664 (SGT-HEM), mg/L Total suspended Solids, mg/L pH, Standard units Permit Limit - 15 50 or 100 see permit 6.0 - 9.0 619 For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here. SWU-250 last revised October25, 2012 Page I of 2 STORM EVENT CHARACTERISTICS: Dater (first event sampled) Total Eve t Precipitation (inches): �. Dateiazkhist each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): �--- Note: if you report a sample value in excess of the benchmark, you must implement Tier 1, Tier Z or firer 3 responses. See Genera! Permit text. FOR PART A AND PART B MONITORING RESULTS: • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B • 2 EXC€EDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B, • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑ IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mail -an ariuinal and one cony of this PAR, inducting all "Na Discharge" reports, within 30 days of receipt of the lab results (or at end of monitorfrra period in the case o "No Dischar e" rep-o-r1sl to., Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Rale#gh, North Carolina 27699-1617 YOU MU51 SIGN THI5_CWTiFICAjLQN FOR ANY INFORMATION REPORTER: "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible forgathering th-6'Information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there as sig ficant penalties for submittin false information, including the possibility of fines and imprisonment for knowing vioiatlons." (Date) Additional copies of this form may be downloaded at: SWU-250 last revised October 25, 2012 Page 2 nf2 Semi-annual Stormwater Discharge Monitoring Report for North Carolina Division of Water Quality General Permit No. NCGO80000 Date submitted August 12 2016 CERTIFICATE OF COVERAGE NO. NCG08_,0_,,, _3_ _3_ _4_ FACILITY NAME Republic Waste Services Inc. — Winston Salem_ COUNTY Forsyth PERSON COLLECTING SAMPLES Mark Tabacznski LABORATORY ENCO Lab Cert. ## 591 Comments on sample collection or analysis: SAMPLE COLLECTION YEAR 2016 SAMPLE PERIOD ® Jan -June ❑ July -Dec or ❑ Monthly' tmonth DISCHARGING TO CLASS ❑ORW ❑HQW []Trout ❑PNA []Zero -flow ❑Water Supply ❑SA RECEIVED ®Other C, PLEASE REMEMBER TO SIGN ON THE REVERSE 4 AUG 17 Z016 Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _x_ yes _no (if yes, report your analytical results in the table immediately below) CENTRAL FILES DWR SECTION Part A: Vehicle Maintenance Areas Monitoring Requirements (If applicable) No discharge this period' `Outfall "No. I Date.., ,;. Sample Collected, mo/iiii/yr 00530 , 00400 +00556„ TptaI Suspended" Soliiis, mg/,L' pH, Standard°units z f Non=Polar;Oil�and3Grease%TP,HftPA ; ._ Method 1664((SGT HEM);Fmg%L; q" jNew Motor OilsUsage, = , ARnual average1al/rno Benchmark. - , .. >.. _. . °50t"or�'100 see permit,. Within 6 0=so , :15 001 06/27/16 6.2 7.0 <3.15 >55 Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals (If applicable) . Outfall. No. Date' SampWC-bllected, mo/,d_d%yr 00556 - 00530 0 . ° 00400- . Non=Polar-Oi['and.Grease/TPH,"EPA Method 1664":(SGT=HEM)� mg/L.<;., -Total"Suspended,Solids,� " " ,n mg/ r° pH, Standardaunifs.. Permit iLirriit - - 15 - 50"or,100 see..permit "6.0 — 9,o i For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here. SWU-250 last revised April 11, 2013 Page I of 2 STORM EVENT CHARACTERISTICS: Date _06/27/2016 (first event sampled) Total Event Precipitation (inches): 0.11 Date (list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text. FOR PART A AND PART B MONITORING RESULTS: • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART It SECTION B. • 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B. • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES ❑ NO ❑ IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mail an original and one copy of this DMR including all "No Discharge" reports, within 30 days of receipt of the lab results for at end of monitoring period in the case of "No Discharge" reports) to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations." (Signature of Permittee) % Z 4," 2.vir. (Date) Additional copies of this form may be downloaded at: http://Portal.ncdenr.org/web/wq/ws/su/npdessw#tab-4 S WU-250 last revised April 11, 2013 Page 2 of 2 Semi-annual Stormwater Diseharize Monitoring; Revortz4ez�, for North Carolina DivisJoin of Water Oua'llty General Permit No. NCG080000 Date submitted 7)15' CERTIFICATE OF COVERA4rjE NO. NtA3U5_\j 13 o FACILITY NAME NtP)01"- VAdl S49VY,44., COUNTY fl-lbl%� - PERSON COLLECTING SAMPLESmw LABORATORY Lab Cert. # Comments on sample collection or analysis: Part A: Vehicle Maintenance Areas Monitoring Requirements SAMPLE PERIOD E]Jan-June JYJuly-Dec or El Monthly' Jmonthj RECEMING TO CLASS E]ORW []HCtW -E]Trout [:]PNA Elzero-flow Elwater Supply E]SA []Other DEC 0 4 M� CENTRAL FILES PLEASE REMEMBER TO SIGN ON THE REVERSE 4 D\IVR SECTION [] No discharge this period-' A. b. iu 4 a,-1 0 N7 Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month?_ yes _no (if yes, report your analytical results in the table immediately below) Part B: Oil/water Separators and Secondary Containment.Areas at Petroleum Bulk Stations and Terminals I For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here. SWU-250 last revised October 25, 2012. Page I of 2 STORM EVENT CHARACTERISTICS: Date 4irst event sampled) Total Event Precipitation (inches): Date (list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Note: If you report a sample value In excess of the benchmark, you must Implement 77er 1, Tier 2, or, Tier 3 responses. See General Permit text. FOR PARS A AND PART B MONITORING RESULTS: • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART 11 SECTION B. • 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER ATTHE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART it SECTION B, • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑ IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mail an original and one coat► of this AMR, including all "No Dlscharae" reports. within 30 days of receipt of the lab results for at end of monitoring,V R4 in the case of'ft Discharge"reaarts) to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision In accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there,�are significant penalties for submitting false information, including the possibility of fines and. imprisonment for knowing violations." l 1 A (Signature of Permittee) /r J V f/✓ (Date) Additional copies of this form may be downloaded at: htt ortal.ncdenr,or web w ws su n dessw#tap-4 SWU-250 last revised October 25, 2012 Page 2 of 2 Semi-annual Stormwater Discharge Moiniftoring Rel2ort for North Carolina Division of Water Quality General Permit No. NCGO80000 Date submitted CERTIFICATE OF COV RAG N0. NC�j _ ��` ✓ `,'C(t.,�g�SAMPIE COLLECTION YEAR FACILITY NAME �4 7z Ch�"J SAMPLE PERIOD g1an-June ❑ Ju1y-Dec COUNTYor Monthly' month PERSON COLLECTI G SAMPLES Rims SS ❑ORW ❑IfQW []Trout❑PNA LABORATORY jf. v/V o lab Cert. q e— Otero -flow 'OWater Supply OSA Comments on sample collection or analysis: JUL 4 8 ry03� ❑Other Part A: Vehicle Maintenance Areas Monitoring Requirements CENTRAL FIL-q ASE REMEMBER TO SIGN ON THE REVERSE 3 DWR SECTIO No discharge this period' No... :., :Dete' : ac . Sample troll8cted, rncJ/dd/ �r.. 00530. 00400 .: 00556 .. Tntal Suspended al Solid's; rOg/l. pM; : :. Standattf-units'.. Non -Polar Off and:Grease/TM A :: Method �664.(SGT HEMj;.mg/L New Motor0il.Usage, . Annual avers e'gal%ma. Benchmark ; 54 or �00'see. 'ermif Withln.6s0 .:, 9.0 .r 7.0 .2,G coN —1—r- elG ,0 2. Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? _ yes _no (if yes, report your analytical results in the table immediately below) Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals o ltfall No. Date :. Sample Coliectid,, ma/dd%yr 00 6:'., 00530 00400 .'Non -Polar 011'and Grease/TPH PA:Method` ' 1664 [SGT-HIEM), mg/L ; ` Total Suspended Solids, mg/L.:.. 5tandaid;uh.16. Permit l.lmit 15 so or 100 see pemit j 6.0., 9.0. I For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here. SWU-250 last revised October 25, 2012 Page I of 2 STORM EVENT CHARACTERISTICS: w Date (first event sampled) Total Event Precipitation (inches): Date (list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text. FOR PART A AND PART B MONIT RARE UL • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B. • 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART ll SECTION B. • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑ IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Malan 2E&Lnal gndDMR including ail "No Di char e" [Mq& Withino days of rec i t of the lob result or at gndmont3gorina period in Me WEe gt nW Qischarge"reports) ba: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATIQN RE 0 TED: "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for Mhering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there alp significant p9fiallies for submitting false information, including the possibility of fines and imprisonment for knowing violations." of Permittee) 2-3-/S- (Date) Additional copies of this form may be downloaded at: http://portal.ncdenr.of'g/web/wa/ws/su/npde5swhtab-4 SWU-250 Iasi revised October 25, 2012 Page 2 of 2 - r } Semi-annual Stormwater Discharge Monitoring Report for North Carolina Division of Water Quality General Permit No. NCG080000 Date submitted CERTIFICATE OF CWWV N011 ,N,C 08 O "t SAMPLE COLLECTION YEAR FACILITY NAME �✓4 .��►'�c.: fit%>;^S Q°r" SAMPLE PERIOD XJan-June ❑ July -Dec COUNTY AxVgN or ❑ Monthly' _(month) PERSON COLLE =IG MPLES `DIIS/CHHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA LABORATORYe� Lab Cert, #y_�_ �EC�1 V Ea ❑zero -flow '❑Watersupply []SA Comments on sample collection or analysis: []Other JUL Q S Z015 Part A: Vehicle Maintenance Areas Monitoring Requirements PLEASE REMEMBER TO SIGN ON THE REVERSE CENTRAL FILES DWR SECTION ❑ No discharge this period' atrtfall ' No .... . Date Sample Collected, :.. n oldd/.yr. 00530,. .. 00400 00556 .. 'Tatal Suspehded " . Salids, mg%L :.' :. pli,' Siand6H-'6 tits :. '.. -Non Polar 011 ar4GreaseJTPH EPA Method:'166i4,(SGT-FIE.M};.rn L New, Motor Oil lJsage, Arhual avers �e; l%rT o Benchtnack ' . :,. :50 or 100'see:perrntt Vililhln ... J J.. 3 7 7, 0 O Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ,e/yes _no Of yes, report your analytical results in the table immediately below} Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals Outfall No :. : `Date Sample Collected,.- rr>io/dd%yr . 00556. .00530 06400 Non-P61ar Oil and GreasejTPH I:PA Method`"' .. -.... 1564 (SG#-HEMJ,,mg%L ,: Total�Susgerided Solids, ..mg/L . pH; StaOdard;units Permit ilMit 15 So or 100 see permit .6.0 =9.0 I For sampling periods with no discharge at any single outfali, you must still submit this discharge monitoring report with a checkmark here. SWU-250 last revised October25, 2012 Page I of 2 t!� STORM EVENT CHARACTERISTICS: Date— / Ar (first event sampled) Total Event Precipitation (inches): - 1 - Date (list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Note: If you report a sample value in excess of the benchmark, you must implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text. FOR PART A AND PART B MONITORING RESULTS: • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART 11 SECTION B. • 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER ATTHE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART 11 SECTION B. • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mail an orlainalg—nd one cony of this DMR. Including all "No Discharae" reports, within 30 days of receipt of the lab results for at end of mQi�nrIngi2eriod in the case of "No Dysthargeu re -Ports) to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIgN THIS CERTIFICATION FOR ANY INFORMATION REPORTED_ "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for g3theri the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are Ificant Pena f r submitting ing false information, including the possibility of fines and i/00 mprisonment for knowing violations." 1 —3— (Signature of Permittee) (Date) Additional copies of this form may be downloaded at: http:/fportaL.ncdenr.orelweblwgJwslsunpdessw#tab-4 SWU-250 last revised October 25, 2012 Page 2 of 2 Semi-annual Stormwater Discharge Monitoring Report for North Carolina Division of Water Quality General Permit No. NCG080000 Date submitted CERTIFICATE OF COVERAGE NO, N� ,C OSQ a- t' r FACILITY NAME P&Q30\tc, COUNTY . �, gy;N PERSON COLLECTING SAMPLES LABORATORY f CO LD S Lab Cert. # Comments on sample collection or analysis: Part A: Vehicle Maintenance Areas Monitoring Requirements SAMPLE COLLECTION YEAR 31V SAMPLE PERIOD ❑ Jan -June July -Dec or ❑ Monthly' (monthl DISCHARGING TO CLASS ❑ORW ❑HQW ❑Trout ❑PNA []zero -flow ❑Water supply [:]SA NECEIVED ❑Other NOV 19 2014 CENTRAL FILES DWR SECTION PLEASE REMEMBER TO SIGN ON THE REVERSE 4 ❑ No dischorge this period' Outfall" No.' Date Sample Collected, mo/dd%yr 00530 00400 00556 Total Suspended Solids, mg/L pH, . Standard units Non -Polar Oil.and Grease/TPH EPA Method 1664-(SGT-HEM), mg/L New Motor Oil Usage, Annual average gal/mo Benchmark. - 50 or'100 see permit Within 6.0"9.0 15 . " - O O Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor oil per month? ✓yes _no (if yes, report your analytical results in the table immediately below) Part B: Oil/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals Outfall No. Date Sample Collected, mo/dd/yr 00556 00530 00400 . ' Non -Polar Oil and Grease/TPH EPA Method 1664 (SGT-HEM), mg/L Total Suspended Solids, mg/L pH, Standard units Permit'Limit - . 15 50 or100 see permit 6.0 -- 9.0 I For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here. SWU-250 d' last revised October 25, 2012 Page I of 2 STORM EVENT CHARACTERISTICS: Date Of" (first event sampled) Total Event Precipitation (inches): Date (list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (inches): Note: if you report a sample value in excess of the benchmark, you must implement Tier I, Tier 2, or Tier 3 responses. See General Permit text. FOR PART AAND PART B MONITORING RESULTS: • A BENCHMARK EXCEEDANCE TRIGGERS TIER 1 REQUIREMENTS. SEE PERMIT PART II SECTION B. • 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER AT THE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS. SEE PERMIT PART II SECTION B. • TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANYONE OUTFALL? YES []No ❑ IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mail an oriainal and one copv of this DMR. includina all "No Discharae" reports, within 30 days of receipt of the lab results for at end of monitoring period in the case o "No Discharge" Worts) to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU MUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are signifi nt penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations." (Signature of Permittee) (Date) Additional copies of this form may be downloaded at: http://portal.ncdenr.org/web/wct/ws/su/npdessw#tab-4 SWU-250 last revised October 25, 2012 Page 2 of 2 Semi-annual Stormwate_r Discharge Monitoriniz Report for North Carolina Division of Water Quality General Permit No. NCGO80000 Date submitted CERTIFICATE OF CO RA N0. NCg08_, SAMPLE COLLEC 0 YEAR �o FACILITY NA E +G 2(f- •c 4#/VC w SAMPLE PERIOD Jan -June ❑ July -Dec COUNTY I' or ❑ Monthly'_ _ � _ (month]_ ARGING TO CLASS ORW HQW Trout PNA PERSON CO Y ING SAMPLES U _ Zero -flow []Watersupply ❑SA LABORATORY co-NGJ Lab Car Comments on sample collection or analysis: JUN 3 0 2014 ❑Other CENTRAL FILES PLEASE REMEMBER TO SIGN ON THE REVERSE -� Part A; Vehicle Maintenance Areas Monitoring Requirements DWQ/80G [] No discharge this period' Outfal I No. Date Sample Collected, rno/dd/yr 00530 00400. 00S56 Total Suspended Solids, mg/L pH, Standard units Non -Polar Ail and Grease/TPH EPA Method 1664 (SGT-HEM), mg/L New Motor Oil Usage, Annual average gal/mo Benchmark i. 50 or 100 see permit Within'6:0— 9.0 15 - S l 0I Did this facility perform Vehicle Maintenance Activities using more than 55 gallons of new motor all per month? _yes —no (if yes, report your analytical results in the table immediately below) Part B: Off/water Separators and Secondary Containment Areas at Petroleum Bulk Stations and Terminals Outfall No. Date Sample Collected, mo/dd/yr 00556 00530 00400 Non -Polar Oil and Grease/TPH EPA Method 1664 (SGT-HEM), mg/L Total Suspended Solids, mg/L pH, Standard units Permit Limit - 15 50 or 100 see permit 6.0 — 9.0 I For sampling periods with no discharge at any single outfall, you must still submit this discharge monitoring report with a checkmark here. SWU-250 last revised October 25, 2012 Page I of 2 STORM EVENT CHARACTERISTICS: Date (first event sampled) Total vent Precipitation (inches): •u Date _ )list each additional event sampled this reporting period, and rainfall amount) Total Event Precipitation (Inches): Note: If you report a sample value In excess of the benchmark, you must Implement Tier 1, Tier 2, or Tier 3 responses. See General Permit text. FOR PART AND PART B MONITORING RESULTS: • A BENCHMARK EXCEEDANCE TRIGGERS TIER I REQUIREMENTS. SEE PERMIT PART it SECTION B. • 2 EXCEEDANCES IN A ROW FOR THE SAME PARAMETER ATTHE SAME OUTFALL TRIGGER TIER 2 REQUIREMENTS, SEE PERMIT PART 11 SECTION B. 0 TIER 3: HAS YOUR FACILITY HAD 4 OR MORE BENCHMARK EXCEEDENCES FOR THE SAME PARAMETER AT ANY ONE OUTFALL? YES ❑ NO ❑ IF YES, HAVE YOU CONTACTED THE DWQ REGIONAL OFFICE? YES ❑ NO ❑ REGIONAL OFFICE CONTACT NAME: Mall an orlainal and one coov of this AMR, includina all "No Oisc_h_arae" reports, within 30 days of receipt of the lab results or at end_of morritorina Period In the case of "No Aischarae" reports) to: Division of Water Quality Attn: DWQ Central Files 1617 Mail Service Center Raleigh, North Carolina 27699-1617 YOU BUST SIGN THIS CERTIFICATION FOR ANY INFORMATION REPORTED: "I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the Information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significint penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations," of Permlttee) 6 -�y (Date) Additional copies of this form may be downloaded at: http://Portal.ncdenr.oEg/web/wglw jsu/npdessw#tab-4 SWU-250 last revised October 25, 2012 Page 2 of 2